Training doctors to be patient advocates

Keystone residents get to know the communities and resources available in areas where their patients live, such as this triple-decker lined street in Boston. (Piotrus/Wikimedia Commons)

On a cool morning in September, a shuttle bus full of first year pediatric medical residents pulls up alongside a curb in Dorchester, one of the poorest areas of Boston. The doctors disembark and disperse in groups of twos and threes. They’re not making house calls or working in an area clinic. They have an appointment with housing court.

The residents are starting their “Keystone Quarter,” an innovative twelve week program launched by the Boston Combined Residency Program (BCRP) in July 2013. Keystone combines three previously distinct rotations—adolescent medicine, developmental/behavioral pediatrics and advocacy—into a single three-month block. Content from each discipline is broken up and spread out longitudinally; instead of spending four weeks each on advocacy, behavioral health and adolescent medicine, residents experience segments of all three curricula every week for twelve weeks.

On a typical day, a Keystone resident may spend the morning visiting a food pantry in Roxbury and the afternoon working in a behavioral health clinic at Boston Medical Center. The next day she might start at Boston Children’s Hospital’s adolescent health center and end at the library, researching how medical translators can improve health outcomes in immigrant communities. Residents gain first-hand knowledge about the everyday challenges their patients are facing by meeting with administrators at WIC offices (Women, Infants and Children federal assistance program), observing HeadStart classes and sitting in on eviction hearings.

“You have to understand the social determinants of health to be an adequate practitioner in the clinical setting,” says Kristin Schwarz, MD, a BCRP resident who was in the second class to complete Keystone. “The Keystone Quarter provides unique learning opportunities for residents to understand the neighborhood environments and day-to-day challenges their patients face.”

Connecting the dots

Keystone was designed to address multiple issues that had been weighing on the minds of BCRP leaders for years. First, they felt that the traditional residency model of two-to-four week “blocks” focusing on a specific pediatric subspecialty—cardiology, gastroenterology, emergency medicine, etc.—might not foster an inclusive, holistic approach to multi-system care. And while bright young doctors were learning the most up to date and innovative approaches to treating acute diseases, they were not getting enough exposure to the kinds of chronic, longitudinal health issues that plagued low income communities right around the corner.

“We started to step back and think: Are residents getting a good sense of the interconnection between disciplines? Were they learning how to work in inter-professional groups?” says Catherine Distler, MD, co-program director in the BCRP.

When the Accreditation Council for Graduate Medical Education (ACGME) mandated that residency programs incorporate an advocacy component, the spinning wheels in Distler’s and her colleagues’ minds picked up speed. What if there was a way to combine a more hands-on, deeper dive into the everyday practice of pediatric medicine with community health and advocacy?

Thus the Keystone Quarter was born.

Designing a unique experience

BCRP leaders worked to infuse this unique residency block—which is a requirement, not an elective- with the perfect balance of flexibility and structure.

The traditional developmental/behavioral pediatrics block involved working with as many as 20 different supervising clinicians. Now, Keystone residents return to the same care team on a weekly basis. This allows for trust to grow, and ultimately residents assume more responsibilities and gain more hands-on experience. They have more opportunity to take a lead role in patient care and can observe a wider variety of conditions and health concerns.

Behavioral and developmental medicine is a complex field of medicine that relies heavily on effective collaboration between psychiatrists, doctors, nurses and social workers. Residents must learn to work as part of an interdisciplinary team, as well as engage in difficult conversations with patients and families about test results and long-term expectations.

The advocacy curriculum combines lecture-style classes with hands-on experience (such as testifying at the state capitol in support of child health initiatives) and individual projects. Distler adds that residents are trained in writing op-eds and working with news media to spread messages about public health issues. All residents must complete an advocacy project on the topic of his/her choice, and can work closely with the Government Relations department at Boston Children’s to advance legislation concerning child health on the state or federal level.

“You have to understand the social determinants of health to be an adequate practitioner in the clinical setting.”

Schwarz’s project focused on poverty’s impact on health outcomes. She created a “pocket card” for clinicians to carry and use in clinic visits to initiate difficult conversations with their patients and their patients’ parents to uncover information about social determinants to health such as housing security, access to healthy food, and educational resources for children.

“The questions were carefully written to be sensitive and non-judgmental,” says Schwarz. “For example, ‘Do you ever have trouble paying for heat or electricity?’ ‘Do you have any questions about your immigration status?’”

Integrating advocacy with patient care

The Keystone schedule notably carves out time for afternoon visits to neighborhoods in Boston where residents perform community assessments. “The goal is for them to become advocates for their patients by becoming more aware of socioeconomic disparities and unique community resources,” says Distler.

Schwarz recalls the day she and a small group of residents took a bus to Dorchester, tasked with finding affordable child care, fresh food, safe parks and housing for a family of four. “That experience really helped us understand our patients more, and be better prepared to connect them to resources.”

While every residency program in the country must address advocacy in some way to comply with the new ACGME rules, Keystone stands out for its integrative, robust approach. “It’s definitely a model that can be replicated elsewhere,” says Schwarz.

Distler says the response from residents who have completed the program has been largely positive. While at first many thought Keystone would be a “lighter” schedule compared to a typical rotation, they soon realized that it wasn’t lighter, just different. “They were traveling across town a lot and had to be able to apply concepts as they learned them in real time,” says Distler. “It was fun to watch the residents think critically about their chosen issues, dig deep, and work on projects that had really far-reaching impacts.”